<form id="form69" name="form69" class="wufoo topLabel page" autocomplete="off" enctype="multipart/form-data" method="post" novalidate
action="">

<ul>

<li id="foli0" class="notranslate      ">
	<label class="desc" id="title0" for="Field0">Name</label>
	<span>
		<input id="Field0" name="Field0" type="text" class="field text fn" value="" size="8" tabindex="1" />
		<label for="Field0">First</label>
	</span>
	<span>
		<input id="Field1" name="Field1" type="text" class="field text ln" value="" size="14" tabindex="2" />
		<label for="Field1">Last</label>
	</span>
</li>
<li id="foli2" class="complex notranslate      ">
	<label class="desc" id="title2" for="Field2">Address<span id="req_2" class="req">*</span></label>
	<div>
		<span class="full addr1">
			<input id="Field2" name="Field2" type="text" class="field text addr" value="" tabindex="3" required />
			<label for="Field2">Street Address</label>
		</span>
		<span class="full addr2">
			<input id="Field3" name="Field3" type="text" class="field text addr" value="" tabindex="4" />
			<label for="Field3">Address Line 2</label>
		</span>
		<span class="left city">
			<input id="Field4" name="Field4" type="text" class="field text addr" value="" tabindex="5" required />
			<label for="Field4">City</label>
		</span>
		<span class="right state">
			<input id="Field5" name="Field5" type="text" class="field text addr" value="" tabindex="6" required />
			<label for="Field5">State / Province / Region</label>
		</span>
		<span class="left zip">
			<input id="Field6" name="Field6" type="text" class="field text addr" value="" maxlength="15" tabindex="7" required />
			<label for="Field6">Postal / Zip Code</label>
		</span>
		<span class="right country">
			<select id="Field7" name="Field7" class="field select addr" tabindex="8" >
				<option value="" selected="selected"></option>
				<option value="United States" >United States</option>
				<option value="United Kingdom" >United Kingdom</option>
				<option value="Australia" >Australia</option>
				<option value="Canada" >Canada</option>
			</select>
		<label for="Field7">Country</label>
		</span>
	</div>
</li>
<li id="foli8" class="phone notranslate leftHalf     ">
	<label class="desc" id="title8" for="Field8">Phone</label>
	<span><input id="Field8" name="Field8" type="tel" class="field text" value="" size="3" maxlength="3" tabindex="9" /><label for="Field8">###</label></span>
	<span class="symbol">-</span>
	<span><input id="Field8-1" name="Field8-1" type="tel" class="field text" value="" size="3" maxlength="3" tabindex="10" /><label for="Field8-1">###</label></span>
	<span class="symbol">-</span>
	<span><input id="Field8-2" name="Field8-2" type="tel" class="field text" value="" size="4" maxlength="4" tabindex="11" /><label for="Field8-2">####</label></span>
</li>
<li id="foli9" class="notranslate rightHalf     ">
	<label class="desc" id="title9" for="Field9">Email<span id="req_9" class="req">*</span></label>
	<div><input id="Field9" name="Field9" type="email" spellcheck="false" class="field text medium" value="" maxlength="255" tabindex="12" required /> </div>
</li>
<li id="foli12" class="date notranslate leftHalf     ">
	<label class="desc" id="title12" for="Field12">Arrival Date</label>
	<span><input id="Field12-1" name="Field12-1" type="text" class="field text" value="" size="2" maxlength="2" tabindex="13" /><label for="Field12-1">MM</label></span> 
	<span class="symbol">/</span>
	<span><input id="Field12-2" name="Field12-2" type="text" class="field text" value="" size="2" maxlength="2" tabindex="14" /><label for="Field12-2">DD</label></span>
	<span class="symbol">/</span>
	<span><input id="Field12" name="Field12" type="text" class="field text" value="" size="4" maxlength="4" tabindex="15" /><label for="Field12">YYYY</label></span>
	<span id="cal12"><img id="pick12" class="datepicker" src="<?=base_url();?>images/form/calendar.png" alt="Pick a date." /></span>
</li>
<li id="foli13" class="date notranslate rightHalf     ">
	<label class="desc" id="title13" for="Field13">Departure Date</label>
	<span><input id="Field13-1" name="Field13-1" type="text" class="field text" value="" size="2" maxlength="2" tabindex="16" /><label for="Field13-1">MM</label></span> 
	<span class="symbol">/</span>
	<span><input id="Field13-2" name="Field13-2" type="text" class="field text" value="" size="2" maxlength="2" tabindex="17" /><label for="Field13-2">DD</label></span>
	<span class="symbol">/</span>
	<span><input id="Field13" name="Field13" type="text" class="field text" value="" size="4" maxlength="4" tabindex="18" /><label for="Field13">YYYY</label></span>
	<span id="cal13"><img id="pick13" class="datepicker" src="images/calendar.png" alt="Pick a date." /></span>
</li>
<li id="foli10" class="notranslate       ">
	<label class="desc" id="title10" for="Field10">Accommodation Status</label>
	<div>
		<select id="Field10" name="Field10" class="field select medium" tabindex="19" > 
		<option value="" selected="selected"></option>
		<option value="Single" >Single</option>
		<option value="Couple" >Couple</option>
		<option value="Group" >Group</option>
		<option value="Family" >Family</option>
		<option value="Roommate Selected" >Roommate Selected</option>
		<option value="Need Roommate" >Need Roommate</option>
		<option value="Without Accommodations" >Without Accommodations</option>
		</select>
	</div>
</li>
<li id="foli11" class="notranslate">
	<label class="desc" id="title11" for="Field11">Special Needs</label>
	<div><textarea id="Field11" name="Field11" class="field textarea medium" spellcheck="true" rows="10" cols="50" tabindex="20" onkeyup=""></textarea></div>
</li> 
<li class="buttons ">
	<div><input id="saveForm" name="saveForm" class="btTxt submit" type="submit" value="Submit"/></div>
</li>

</ul>

</form> 